高质量发展背景下医院电子病历质控体系建设的思考  

Reflection on the construction of electronic medical record quality control system under the background of high-quality development

作　　者：东振彩[1] DONG Zhencai(Tianjin Children’s Hospital,Tianjin 300134,China)

机构地区：[1]天津市儿童医院/天津大学儿童医院/天津市儿童出生缺陷防治重点实验室,天津300134

出　　处：《现代医院》2025年第1期65-67,71,共4页Modern Hospitals

基　　金：天津市医院协会课题(2022zc07)。

摘　　要：目的建立电子病历质控评价体系,有效提升数据质控能力,加快形成电子病历理论体系框架构建,推动以电子病历质控体系建设为核心的公立医院高质量发展进程。方法基于霍尔三维结构模型,构建质量管理体系结构,将时间维、逻辑维和知识维融为一体,切实发挥监管机制作用,有效提升管理水平,形成适用于临床、功能持续提升的高效管理体系。结果运行病历各类别缺陷率持续下降,会诊记录缺陷率、手术记录缺陷率呈现大幅降低。结论基于霍尔三维结构的住院电子病历质量管理体系建设,可有效推动电子病历系统高效运行,发挥功能性引导作用。Objective To establish an evaluation system for electronic medical record quality control,effectively enhance data quality control capabilities,accelerate the construction of the theoretical framework for electronic medical records,and promote the high-quality development of public hospitals with the construction of the electronic medical record quality control system as the core.Methods Based on the Hall three-dimensional structure model,a quality management system structure is constructed,integrating the dimensions of time,logic,and knowledge,effectively leveraging regulatory mechanisms,and improving management levels to form an efficient management system applicable to clinical practice and continuous functional improvement.Results The defect rates of various categories of medical records have continuously decreased,and the defect rates of consultation records and surgical records have shown significant reductions.Conclusion The construction of the inpatient electronic medical record quality management system based on the Hall three-dimensional structure can effectively promote the efficient operation of the electronic medical record system and play a guiding role in functionality.

关 键 词：电子病历 数据质量 指标 体系 

分 类 号：R197[医药卫生—卫生事业管理]